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PROTOCOLS AND INFORMATION FOR USE OF GOVERNMENT HOUSE GROUNDS The grounds of Government House may be made available, at the Governor’s discretion, for charitable and community functions. They are not made available for hire, or for use for commercial purposes. All costs associated with conducting a function in the grounds of Government House are at the expense of the organisation requesting use of the grounds. Government House has a moral and legal obligation to provide a safe workplace under the Work Health and Safety Act 2012 and the Work Health and Safety Regulations 2012. As a condition of using the grounds you must take reasonable care to protect your health and safety, as well as that of others that may be affected by your actions or omissions. The following document outlines the practical considerations and legal obligations of the organisation arranging a function in the grounds of Government House, a timeline of requirements and Government House map. Failure to follow these requirements may result in withdrawal of the Governor’s consent for your organisation to hold their function. Briefing by Government House Once favourable consideration has been provided by the Governor for an organisation to host a function in the grounds of Government House, a meeting between the Government House Protocol Team and the organisation is required to formalise the function. This meeting is to ensure the function will be able to meet the requirements of Government House, general details are agreed to, and a Government House WHS induction is provided. Areas of Government House to be used Government House will advise which areas of Government House will be made available for use for the function. Access to Government House or use of any facilities inside the house, such as kitchen and toilet facilities, are not available. Movement by the function patrons will be confined to the immediate area of the function. Number of guests Government House must be advised of the approximate number of guests attending the function at the time of the request to hold a function on the grounds is made to the Governor. Many requirements, obligations and emergency procedures are dependent on the number of guests attending the function.

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PROTOCOLS AND INFORMATION FOR USE OF

GOVERNMENT HOUSE GROUNDS The grounds of Government House may be made available, at the Governor’s discretion, for charitable and community functions. They are not made available for hire, or for use for commercial purposes. All costs associated with conducting a function in the grounds of Government House are at the expense of the organisation requesting use of the grounds. Government House has a moral and legal obligation to provide a safe workplace under the Work Health and Safety Act 2012 and the Work Health and Safety Regulations 2012. As a condition of using the grounds you must take reasonable care to protect your health and safety, as well as that of others that may be affected by your actions or omissions. The following document outlines the practical considerations and legal obligations of the organisation arranging a function in the grounds of Government House, a timeline of requirements and Government House map. Failure to follow these requirements may result in withdrawal of the Governor’s consent for your organisation to hold their function. Briefing by Government House Once favourable consideration has been provided by the Governor for an organisation to host a function in the grounds of Government House, a meeting between the Government House Protocol Team and the organisation is required to formalise the function. This meeting is to ensure the function will be able to meet the requirements of Government House, general details are agreed to, and a Government House WHS induction is provided. Areas of Government House to be used Government House will advise which areas of Government House will be made available for use for the function. Access to Government House or use of any facilities inside the house, such as kitchen and toilet facilities, are not available. Movement by the function patrons will be confined to the immediate area of the function. Number of guests Government House must be advised of the approximate number of guests attending the function at the time of the request to hold a function on the grounds is made to the Governor. Many requirements, obligations and emergency procedures are dependent on the number of guests attending the function.

Guidelines for use of Government House Grounds 2

Invitations and promotion of the function A draft copy of invitations, any advertisement for the function or media releases must be submitted to Government House for approval prior to release. To assist organisations to work to strict timelines, Government House will give approval as promptly as possible. Guest list Government House is an apolitical venue and it is essential to be mindful of this when issuing invitations. For example, if a Minister is to be invited, it is preferable for the Shadow Minister to also be invited. Government House requires a final guest list to be provided prior to the function. Briefing information required A function briefing sheet, supplied by Government House, is required to be completed three weeks prior to the function. This will allow a brief to be prepared for the Governor outlining the Governor’s role and function formalities. Speeches It is generally accepted that the Governor will be asked to provide a brief welcoming address for all functions conducted in the grounds of Government House. The correct protocol is for the Governor to welcome guests at the beginning of formalities before other guest speakers. A draft speech prepared by the organisation for the Governor’s welcome address is to be submitted to Government House three weeks prior to the function date. Signage In general terms, it is important that the Governor and Government House are not aligned, nor seen to be aligned with particular commercial interests in preference to others. Further, it is important to preserve the heritage character of Government House. Accordingly, requests for the display of signs, especially commercial signs, should be discussed with Government House staff. Generally, only discreet signs within marquees will be permitted. Labels and logos on marquees, vehicles and equipment will be considered on a case by case basis. It is not generally permitted for promotional material to be distributed within the grounds. Entry to the Government House grounds All entry to Government House is through the main gates located on the corner of North Terrace and King William Street. By prior arrangement, Government House may approve the use of Kintore Avenue pedestrian gate (please note, extra security is required for use of this gate) or rear access gate for large vehicles. Admission is by invitation or by ticket if a charge is made. If guests are to be charged to attend the function, the proceeds must benefit a non-profit organisation. The cost and manner of sale of tickets is to be determined by the organisation in consultation with Government House. The organisation is to provide staff to be located at the entrance gates to control access and collect tickets. Both pedestrians and cars use this gate so it is essential that care and correct entry procedures are in place to ensure safety at all times.

Guidelines for use of Government House Grounds 3

Car parking Car parking is not available for guests attending the function. Access to the grounds for chauffeur vehicle drop off and collection is available. Limited car parking for staff organising the function will be available in the Government House car park. Costs Cost to public funds is to be restricted to reasonable electrical power and water requirements. Government House will only provide staff support to confirm logistical information, advise on Government House requirements, prepare a brief for the Governor and ensure the organisation meets all Government House obligations and requirements. The organisation arranging the function will be held accountable for the cost of repairing any damage caused by its agents, employees or guests. Water Reasonable usage of fresh water is available. Electricity Reasonable electricity usage is available and locations are marked on the map. Power sources available are a combination of three-phase and standard power. The location of marquees, stage and audio may be subject to power requirements. Marquees, stages and platforms The organisation must liaise with Government House regarding size and location of marquees, stages and other equipment. Sufficient coverage must be provided for all guests and staff in the event of inclement weather or heat. It is the responsibility of the organisation to supervise the installation and erection of equipment and facilities, and ensure the protection of the lawns and gardens. Accordingly, marquees must only be standing for the minimum amount of time possible and may not be left standing over a weekend. Further, before erecting marquees, organisations must liaise with Government House gardeners (via protocol team) who will indicate the location of irrigation infrastructure under the lawn. Organisations must also:

- Prevent any vehicles driving on lawns or pavers - Ensure that trees are not damaged by high vehicles - Prevent damage to lawn edging by the movement of vehicles, and prevent damage

to the underground irrigation system - Ensure that no ice, boiling water or any other liquids are poured onto the lawns (as

they burn the grass very quickly.) - Ensure all contractors adhere to Government House WHS Standards (please refer to

the ‘contractor information’ heading) Please note: It is the responsibility of the organisation to ensure all contractors adhere to these requirements. Reimbursement will be sought for any damage occurred during the setup, duration and dismantlement of the function.

Guidelines for use of Government House Grounds 4

Toilet facilities Government House has a limited number of toilet facilities available for use by patrons attending the function in the grounds. Government House provides the following facilities: Female: two cubicles Male: one cubicle and urinal Disability access: two cubicles It is the responsibility of the organisation to ensure there are sufficient number of toilet facilities (including provision for people with disabilities). If your function exceeds 500 guests for duration of longer than 2 hours additional facilities will be required. However, there may be times, for example if the guests are seated and there is only a short break in proceedings, Government House may require or suggest additional facilities are hired for the convenience of your guests. The table at Annex D provides a recommendation as to the number of toilet facilities which should be available for various numbers of guests over differing periods of time. Lighting Government House provides limited lighting in the form of flood lights under large trees, lighting around the toilet facilities and dull lighting along the gravel drive way. Depending on the nature of your event, this may be sufficient. However, it is the responsibility of the organisation to ensure appropriate lighting is provided for their function, which includes setting up and dismantling. All portable lighting is to be tested and in date. Equipment It is the responsibility of the organisation to ensure the equipment necessary for the function is provided. This includes chairs, tables, crockery, cutlery, glassware, cooking equipment, lights, amplification and electric cables. Electrical equipment - All electrical equipment is to be tested and tagged in accordance with AS/NZS 3760 –

testing and tagging of electrical equipment - Residual circuit devices (RCDs) are to be used where required, including all hand held

electrical appliances and tools - All cable runs are to be appropriately secured and covered where required to prevent

accidental damage or trip hazards - All leads, plugs etc are to be protected from weather and other environmental conditions

(eg water) LPG cylinders Liquid Petroleum Gas Cylinders and Heaters are to be stored and used ensuring compliance with AS/NZS 1595:2002 – the storage and handling of LP Gas. Amusement structures Amusement structures are not to be used or operated unless a current certificate of registration issued by SafeWork SA can be provided. Interstate registrations are not acceptable in South Australia.

Guidelines for use of Government House Grounds 5

Rubbish removal All rubbish is to be removed from the property on conclusion of the function and lawns are to be left clear of any debris, including food waste, bottles and recycling. Bump in and bump out A schedule of bump in and bump out times is required to be provided to Government House. A responsible officer of the organisation must present at all times when stores are being delivered or returned, during the function, and when any other work is being done. Security The security of Government House is monitored at all times. Depending on the nature of the function, number of guests and advice from government security advisers (obtained by Government House), Government House will advise if additional security is required, at the cost of the organisation. Serving of alcohol Where liquor is to be offered, a copy of a Liquor Licence must be provided to Government House. To obtain information, advice and to apply for a licence, please contact:

Consumer and Business Services Chesser House, 91-97 Grenfell Street, Adelaide SA 5000 Phone: 131 882 www.olgc.sa.gov.au

If you receive advice from Consumer and Business Services that a liquor licence is not required for your event, please provide Government House with a copy of that advice. Preparation and storing of food and beverage It is the responsibility of the organisation to ensure preparation, storing and serving of all food and beverages adheres to the Food Safety Standards requirements. Further details can be found at:-

www.foodstandards.gov.au/consumer/safety/faqsafety Smoking Smoking is discouraged within the grounds of Government House. Government House does have a designated smoking area located near the outside toilets. It is the responsibility of the organisation to ensure all guests and contractors are aware of the smoking restrictions. First Aid It is a Government House requirement that each organisation contacts St John Ambulance to seek advice if St John attendants are required to be present at the function. This will be at the cost of the host organisation. The contact details are as follows:

St John Ambulance Australia 08 8306 6995 or 1300 360 455 www.stjohnsa.com.au

Guidelines for use of Government House Grounds 6

Emergency response plan Government House requests that the organisation completes an Emergency Response Plan for the function (Annex C). Each function which is held on the grounds of Government House varies in terms of numbers attending, structures erected, lighting and sound equipment utilised therefor Government House will advise if the nature of your function requires further considerations made to the plan. If you wish to view our detailed emergency response plan please contact Government House. Government House staff details and contact information A staff member of Government House will be on duty at all times during a function and may be contacted in case of an emergency or other special need by ringing the back (courtyard) door bell or calling the numbers on the function emergency plan. Contractor information It is the responsibility of the organisation to ensure that all contractors and workers onsite have been inducted to Government House grounds by completing the Government House Contractor Induction Form. (Annex B). The completed forms are to be provided to Government House prior to work commencing and all contractors are required to sign in and out at the Guard House. Staff and volunteer induction training Government House requires the organisation to induct all volunteers and staff associated with the function about the emergency response/evacuation plan, function and any other site specific information. Incident reporting Any injuries, incidents, near misses and hazards must be reported immediately or as soon as practicable to Government House and appropriate form completed (Annex E). Risk assessment The organisation is required to complete a risk assessment and provide a copy to Government House four weeks prior to the function. Government House can provide a template risk assessment upon request. The organisation is required to implement the risk management/hazard management strategies identified. Insurance Proof of appropriate insurance cover for the function is to be provided, in particular:-

- effective Public Liability cover with a ‘Goods Sold‘ extension where necessary - the interests of the Government of South Australia are to be noted in respect of the

function

Guidelines for use of Government House Grounds 7

Timeline for information to/from Government House

Written request to the Governor from organisation to hold function in grounds of Government House

4+ months prior to function

Briefing and concept meeting with Protocol Team if favourable consideration has been given

Prior to accepting event, 4+ months prior to function

Subject to Governor’s discretion, formal accept letter and briefing information sent to organisation

4 months prior to proposed function date

Use of Government House Grounds agreement form signed by organisation

One week following receipt of accept letter

Proposed invitations, advertisements and media releases sent to Government House for approval

As required

WHS briefing by Government House to organisation representative

1 month prior to function

Location of marquee, staging etc finalised 1 month prior to function

Risk assessment submitted 1 month prior to function

Draft speech submitted 3 weeks prior to function

Emergency response plan completed 2 weeks prior to function

Function briefing sheet completed 2 weeks prior to function

Copy of liquor licence supplied 2 weeks prior to function

Final guest list 1 week prior to function

Bump-in and bump out schedule 1 week prior to function

Contractor forms completed 1 day prior to bump in

Bump out Immediately following completion of function

ANNEX A: Map of Government House

ANNEX B: Agreement

USE OF GOVERNMENT HOUSE GROUNDS AGREEMENT

To be signed by organisation and returned to Government House

I,

(position)

(organisation)

accept I have read the Protocols and Information for use of Government House Grounds

and agree to abide by the requirements and obligations in respect of the (function)

__________________________________________

on (date)

Signed

Date

ANNEX C: WHS Contractor induction form

GOVERNMENT HOUSE ADELAIDE

Title: Contractor Induction Form - Grounds

Document No: WHS-Form

Status: Version 1

Date: June 2013

Contractor Induction

Date:

Company / Business name:

PURPOSE This document is to inform contractors of requirements to comply with Work Health and Safety responsibilities while working at Government House Adelaide. All contractors must comply with relevant Work Health and Safety Legislation, Regulations, relevant Australian Standards, Codes of Practice and Department of the Premier and Cabinet (DPC), Department of Planning Transport and Infrastructure and Government House policies and procedures. ACCESS TO GROUNDS All contractors access Government House through the Main Gate. Prior to arrival arrangements are to be made with a member of the Protocol Team by telephoning 8203 98--. Normal hours for work to be completed are 7.00am to 5.00pm Monday to Friday, unless otherwise authorised by Government House management. SIGNING IN/OUT (process will not apply for this particular function) Contractors are required to sign in prior to commencing work and sign out on completion of work at the Guard House and wear the contractors pass at all times. Contractors must have completed the Government House Work Health and Safety Induction prior to commencing work. The Government House WHS Induction is to be completed every 12 month period. Copies of the induction are available from a member of the Protocol Team. Once the Induction has been completed it is to be signed and returned to the member of the Protocol Team. KEY CONTACT NUMBERS Protocol Team 82039832 Guard House 82039870 Chief Emergency Response Warden: Troy Mason 82039830 Health & Safety Representative Andrew Danko 82039842 Government House Switchboard 82039800 First Aid Officer Lisa Mills 82039841 First Aid Officer Lauren Baker 82039833

I have read and understand the requirements to comply with WHS responsibilities while working at Government House Adelaide

Name (Print clearly)

Signature Date

Induction conducted by:

Name (Print Clearly)

Signature Date

ADDRESSING THE GOVERNOR OF SOUTH AUSTRALIA OR MRS SCARCE The salutation (greeting) for the Governor at the first encounter of the day is: Your Excellency. PARKING WITHIN GOVERNMENT HOUSE GROUNDS Whilst a contractor is working at Government House parking within the grounds is available in the Staff Car Park. In some circumstances following a request to the Protocol Team (by telephoning 82039832; giving 24 hours prior notice) and dependant on the work being performed short term parking may be available in the rear courtyard. FIRST AID A First Aid Box is available from the host organisation or one is located in the Guard House. SMOKING Smoking is not permitted within the grounds of Government House. DRUGS & ALCOHOL It is not permitted to carry, consume or be affected by alcohol or drugs on site. You must notify Government House management of any person who you believe is a risk to their own health and safety or the health and safety of others due to being affected by alcohol or other drugs. ALARMS, EVACUATION, EXITS AND FIRE EQUIPMENT In the event that an alarm is sounded the emergency evacuation points are near the fountain in the front of the House or in the rear staff car park. Contractors are to comply with all instructions from Government House staff and Security personnel in the event of an emergency. REPORTING INCIDENTS AND HAZARDS All injuries, incidents, near misses and hazards must be reported immediately to the member of the Protocol Team by telephoning 820398__. The Government House Hazard and Incident Report Form is to be completed within 24 hours and given to the Host Organisation who in turn will give it to a member of the Protocol Team. JOB SAFETY ANALYSIS Safe work Method statements/ Job Safety analyses must be prepared by yourself or your employer. You must ensure that you have reviewed, understood and signed the Safe work Method Statement and/or any risk assessment (JSA) for that work before commencing. Copies of the JSA’s are to be given to the Host Organisation, who in turn will give copies to a member of the Protocol Team. PERSONAL PROTECTIVE EQUIPMENT (PPE) PPE appropriate to the industry standard for the trade and task to be performed is to be worn at all times by the contractor. Specific PPE will be documented throughout your SWMS, JSA or other risk assessment documentation. SITE SPECIFIC HAZARDS Contractors are required to consult with the Government House representative to determine any specific hazards in the areas that they will be working. Asbestos Register is located in the rear corridor Hazardous Chemical Register is located in the fire safety board WASTE MATERIAL Contractors are required to remove all waste material from the site on completion of work performed. Hazardous waste is to be disposed of according to the EPA guidelines.

HAZARDOUS SUBSTANCES/DANGEROUS GOODS Contractors using hazardous substances/dangerous goods while within Government House grounds are required to inform the Host Organisation, who in turn will notify Government House staff prior to commencing work. Contractors are required to provide Safety Data Sheets (SDSs) for all hazardous substances/dangerous goods brought to site and have them in an easily accessible area. (Copies of SDSs are to be given to the Host Organisation, who in turn will give copies to Government House.) WORK AREAS Contractors shall restrict their movements and activities within the designated areas, and times as agreed and required by the project or job. Always ensure the work area remains safe and secure for the public and staff. Government House staff or Guards must approve entry into other areas of Government House. TOOLS AND EQUIPMENT Contractors will be responsible for all of their tools and equipment and will secure them in such a way that will prevent any injury or damage to Government House staff or property and visitors. If contractors use any Government House equipment, it is to be returned in good working order and any faults are to be reported to a Government House representative. ELECTRICAL EQUIPMENT All electrical equipment used on Government House premises is to be tested and a current test tag is to be attached. Contractors failing to comply with this will be required to leave the premises and return when the equipment is compliant. Never use electrical equipment without a tested earth leakage protection device (Residual Current Device - RCD). Never remove anyone else’s Danger Tag. GRINDERS Grinders must have a Deadman/Safety Switch system 9” grinders must have ‘D’ handles Eye protection and hearing protection must be work (does not include welder’s masks) SPILLAGE AND CLEAN UP Any spills of fuel, oil, paint, solvent, chemical or pollutant must be reported to management or the Guards immediately. The contractor will be required to participate in completing the environmental investigation and the physical clean up. HOT WORK Prior to commencing any Hot Work (grinding, cutting, welding) contractors are required to complete a Hot Work Permit available at the sign in area and are required to comply with the conditions stated on the permit. WORKING AT HEIGHTS Contractors are required to comply with the relevant legislation and relevant Australian Standards regarding working at heights. The Host Organisation s to inform Government House if working at heights is to be conducted. Appropriate licensing and certification evidence is to be made available for sighting by the Government House representative. Prior to accessing the roof area of Government House the Butler or Footman is to be contacted to outline the Safe Working at Heights equipment that has been installed. Never work at or above 3 metres without fall protection and or fall prevention. SCAFFOLDING All scaffold supplied by a contractor must be erected by a competent person and scafftagged. All scaffold must be inspected every 30 days as per AS/NZ4576. The scafftag on the scaffold must be signed off by the scaffolder.

OPERATING PLANT Equipment should only be operated by persons who are:

trained

competent and

authorised to operate that plant Appropriate licensing and certification evidence is to be made available for sighting by the Government House representative when requested. TEMPORARY STRUCTURES Prior to the erection of temporary structures (marquees, tents, shelters etc.) on Government House grounds Government House staff are to be consulted as to the preferred location. A gardener will mark the location of irrigation lines with flags. As per legislative requirements a construction industry induction (white card) is required prior to beginning works relating to structures. Appropriate licensing and certification evidence is to be made available for sighting by the Government House representative. CONFINED SPACES All personnel required to work in an area defined as a “Confined space” are required to comply with DPC WHS Policy 18 Confined Space Policy and Procedure and related forms and permits, a copy of this documentation is available from the Government House representative.

ANNEX D: Emergency Response Plan

EMERGENCY RESPONSE PLAN

FUNCTION

DATE

EMERGENCY RESPONSE OFFICER

NAME

MOBILE

OTHER CONTACT PERSONS FROM ORGANISATION IN THE EVENT OF AN EMERGENCY

NAME

MOBILE

NAME

MOBILE

Emergency Contact Numbers Government House Emergency Response Warden: 08 8203 9840 / 08 8203 9841

Metropolitan Fire Brigade: 000

Guard House: 08 8203 9871 / 08 8203 9870

St John Ambulance: 000 or onsite presence Access/Egress Guests will normally access and leave the grounds via the Main Gate. In the event of an emergency or if the numbers attending the function are large Government House may open the rear gates on Kintore Avenue and or the small pedestrian gate on Kintore Avenue. Information required Please indicate on the attached map where the following will be located if required:

- Marquees/tents - Stage - Sound equipment - Lighting - Food preparation areas - St John First Aid station - Portable fire extinguishers

Please inform Government House how communication will be conducted to guests in the event of an emergency.

Primary assembly area

at water fountain

Secondary assembly

area in rear car park

ANNEX D: Toilet Facilities

The following table provides a recommendation as to the number of toilet facilities which should be made available for various numbers of guests over differing periods of time.

ANNEX E: Incident Report Yellow parts are those which need to be filled out and given to Government House within 24 hours.

HIRM HAZARD AND INCIDENT REPORT AND INVESTIGATION FORM

1. 1 Person Reporting the Incident/Hazard

Date:

Surname: First Name:

Incident type: (Please select one) Hazard (go to Q.1.3) Near Miss / Incident Injury

1.2 Person Involved Details

Person Involved:

Self Another person For non-employee please tick one of the following:

Contractor Visitor Volunteer Person Type: Employee Non-employee

Surname: First Name:

TO BE COMPLETED in accordance with the Hazard and Incident Report and Investigation standard and forwarded to the manager/ supervisor upon completion of SECTION ONE.

All data from this form is to be lodged electronically onto the HIRM System within 24 hours

( https://saps.sbcit.com.au/incidentform/)

Shaded areas are mandatory and MUST be completed as a minimum

IMPORTANT REMINDER: Immediately report to SafeWork SA any

1. Work related death;

2. Injury or illness that:

requires admittance to hospital as an inpatient; or

results from exposure to any substance that causes acute symptoms; or

3. Dangerous Occurrence see Section 2 page 2

Emergency Telephone:1800 777 209 (24 Hours)

MANDATORY REPORTING OF ALL ELECTRICAL INCIDENTS

All incidents involving electricity must be reported to the Office of the Technical Regulator by the electrical worker or the occupier of the premises where the incident occurred

1. Complete a Electric shock or incident report form available from the Office of the Technical

Regulator, or the Safety and Wellbeing unit 2. Send the completed form to the Office of the Technical Regulator. 3. Report the accident to Safework SA

4. Timelines for Reporting an Electric shock or incident

The timelines for reporting electrical accidents depend on the severity of injuries sustained in the incident.

Death must be reported immediately via telephone.

Any accident where a person requires medical assistance must be reported within one working day.

All other accidents involving electricity must be reported to the Office of the Technical Regulator

within 10 working days of the day of the accident.

For further advice or help contact the Office of the Technical Regulator, Ph: 8226 5500

Gender: Male Female Date of Birth:

If an employee please complete your contact number

1.3 Accident/Incident Cost Centre

Portfolio: Premier & Cabinet Service:

Region: Premier & Cabinet Division:

Agency: Cost Centre:

1.4 Notifications

Supervisor HSR

Manager OHS Consultant

Other

1.5 Incident/Hazard Details

Date of Incident:: Time: AM / PM

Date first reported: Reported to:

Location of Accident/Incident

Alternate Workplace Normal Workplace Travel From Work Travel To Work Travel Within Work

Specific Location:

Address:

Suburb: State: Postcode:

1.6 Description of Incident/Hazard

What happened? (Describe what happened)

What caused the Incident/Hazard?

Witness Yes No

If so, name of witness: Contact Phone:

1.7 Injury Details (If a nears miss go to SECTION 2)

Injury Type: Lost Time Injury Medical treatment First Aid No Treatment

If Lost Time Injury: Date Ceased: Time Ceased:

Bodily Location of Injury/Disease (eg: left eye, Upper left leg multiple locations):

Description of Illness/Injury:

Details on how Injury/Disease was sustained:

1.8 Incident Question (HIRM will have further information to complete depending on the option chosen)

What category does this incident fall under? Psychological Training

Falls Slips Trips Aggression/Violence Exposure Muscular Stress/Manual Handing

1.9 Treatment Details

If Medical Treatment Sought: First Aid Medical Hospital Other

Form MUST be handed to Government House within 24 hours